EDITORIAL

Tuberculosis in prisons: an avoidable calamity?

There are currently some 350,000 individuals incarcerated in Brazil. Although the country's incarceration rate (191/100,000 inhabitants in 2005) is far short of the world's highest rates (USA 738/100,000, Russia 600/100,000), it has increased by 44% since 2001, increasing the prisons' occupancy rate to 143%. Considering this prison overpopulation and the precarious conditions (confinement in poorly ventilated cells), it is no surprise that tuberculosis (TB), a disease characterized by airborne transmission, poses a major problem for inmates, the majority of whom come from communities where TB is highly endemic and who are repeatedly exposed to the risk of re-infection, as repeat incarcerations are frequent.

In prisons of the State of Rio de Janeiro, the TB incidence rate in prisons (3,532/100,000) was 30 times that of the overall State in 2005, and chest X-ray screening studies in 2002 (n = 6,500 inmates) showed prevalence rates ranging from 4.6% to 8.2%, varying from one prison to another. Some 3% of inmates already have TB upon entering penitentiaries, which may be related to the high endemicity in their original communities, but also to conditions of confinement in police remand jails.

For those who have no experience with prisons, controlling TB in such settings may even sound simple: inmates live in a confined environment and have access to health services, the symptoms are easily identified, the diagnosis is simple, treatment is inexpensive, and supervision is apparently easy, since incarcerated individuals are apparently accessible.

In reality, however, the obstacles are numerous, especially underestimation of the symptoms in a violent setting where concern for immediate survival is paramount; the risk of stigmatization and segregation, considering the importance of individual protection generated by group-belonging and the vulnerability produced by recognition of the disease in an environment where show of strength is crucial; lack of resources, inadequate health services, and difficult access due to the prison authorities' prioritization of security to the detriment of health. Above all, the inmates' restricted autonomy and the resulting reduced participation in their own treatment as well as prevention lead to essentially prescriptive health measures, often to the point of creating new constraints that aggravate those specifically related to incarceration.

In prisons in various countries, health is still viewed not as a right but as a concession by the prison administration. This is true for TB, which will continue to be a fatality until inmates become central actors in their own health. Health promotion, and especially the fight against TB in prisons, requires joint reflection by all actors in the prison community (inmates and families, security staff, health professionals, teachers...), all exposed to TB, concerning participatory strategies adapted to the epidemiological, social, and psychological specificities of this extremely hierarchical setting. In this context, TB control measures will be optimized, particularly if linked to other health programs and accompanied by improved overall prison conditions and visibility for the health problems inherents to the incarcerated persons.

Alexandra Roma Sánchez
Superintendência de Saúde,
Secretaria de Estado de Administração Penitenciária do Rio de Janeiro,
Rio de Janeiro, Brasil.
asanchez@predialnet.com.br

Luiz Antônio Bastos Camacho
Escola Nacional de Saúde Pública Sergio Arouca,
Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.
luiz.camacho@ensp.fiocruz.br

Vilma Diuana
Secretaria de Estado de Administração Penitenciária do Rio de Janeiro,
Rio de Janeiro, Brasil.
vilmadiuana@gmail.com

Bernard Larouzé
INSERM UMR-S 707,
Université Pierre et Marie Curie, Paris, France.
larouze@u707.jussieu.fr